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1987-255 +CEO 'TIFIC,A►.TE OF 0CCi.JPA�l'�TG'' TOWN OF QUEENSSURY WARREN COUNTY, NEW YORKC December ls , 198 7 L7ate $7-z-55 This is to certify that work requested to be dons an Shawn by Permit No. has been completed. D a e 7 ()ne—paLmily Dwe I n This structure may be occupied as a Il ��. Bonner give Locairion ^�,,,,_ 1 (,�, �L� 1 1� �nce J . Fredel3a trine, By Order Town Hoard TOWN OF QUEENSSURY Suitdint & ZaninS I to I i BUILDING PERMIT A. TOWN OF +QUEENSBURY No. WARREN COUNTYr NEW YORK m A m Lawrence J . Fredella PERMISSION is hereby gr anted to Bonner Drive Street. Road or Ave. y OWNER of property located at ri C one—Family Dwelling A in the Town of Queensbury, To Construct or place a information hereto filed an l at the above location in accordance to application together with plot plans and other Y approved and in compliance with the Town of Queensbury Building and Zoning Ordinance. 1. OWNER'S Address is 4 Cherry St . Glens Falls , New York. 4 'J 2. CONTRACTOR or BUI LDER'S Name ,same rD rs G r• 3. CONTRACTOR or BUILDERS Address t6 same 4. ARCHITECTS Name 5. ARCHITECTS Address 6. TYPE of Construction — [Please indicate by X) C> 0 ( 2d wood Frame I ) masonry ( I Steel [ 1 {D a} 7. PLANS and Specifications plan , sp lf.Cation including 6brx2$ ' per plot p ecificat:ians and app No. sewage system and two car attached garage . m r t- B. Proposed Use N One-Family Dwelling 44 $5 . 00 CIO December 1 19 87 $ 101 . 00 PERMIT FEE PAID — THIS PERMIT EXPIRES (if a longer period is required an application for an extension must 6e made to the Building and Zoning inspector of the town of Clueensbury before the expiirmion date.) Dated at the Town of Queensbury this 14th Day of May 19 87 Q for the Town of Queensbury SIGNED BY Bu�ld�ng and Zoning inspector TO BE COMPLETED BY BLDG . DEPT . $ iJ W N OF � i kr✓ /r Application Nov © (� Town 01 Quee!"fit try Permit Issued 19 BUILDING and ZONING DEPARTMENT Permit Expires 19 c Say and Haviland Road, R. D. 1 Box 98 Zoning Designation ' ' MAY 11987 Queensbury, New York 12801 variance No . Site Plan Review No . I � # BUILDING 8e CODE DEPT. Approved by ; APPLICATION FOR EUILDING AND ZONING PERMIT I41- _._ _. * A PERMIT MUST BE OBTAINED BEFORE BEGINNING CONSTRUCTION . ANSWER ALL OF THE FOLLOWING . The undersigned hereby applies for a Building Permit to do the following work which will be done in accordance with the description , plans and specifications submitted , and such special conditions as may be indicated on the Permit . ........ The owner of this pro erty is : 4:� P . O. Address 7 Tax Map No Property Location : v Street number or building lot number Subdivision name ( if applicable) THE PERSO RESPONSIBLE FOR SUPERVISION OF WORK AS REGARDS BUILDING CODES IS : c1 v C Name P . O. Address Tel . No , Name of builder �4W4 '5 Address Tel . Tel . Name of plumbe Address Name of mason �! Address Tel . NATURE OF PROPOSED Wl7RK : * ZONING INFORMATION : -instruction of a new building * A PLOT PLAN MUST BE PREPARED AND SUBMITTED , * Addition to a building drawn reasonably to scale and attached hereto , * Alteration to a building showing clearly and distinctly all buildings . � (no change to exterior dimensions) whether existing or proposed and indicate all set-back. dimensions from property limes . Give Other work (describe) -- * street and number or lot number and indicate whether interior or corner lot . Show location FOR DEMOLITION PERMIT , STATE SIZE AND * of water supply and location and configuration LOCATION OF STRUCTURES AFFECTED . * of septic disposal area % * COMPLETE INFORMATION REQUIRED BELOW . * Size of property � ft . * Existing buildIng ( s ) Size ft X ft . * PROPOSED BUILDING AND 'US�Er :4, � r k � �"� * Existing building ( s ) Use Site of new structure ZC_ ft x 4 10 f t distance from property line oundatio pier/ slab/crawl/partial/full Proposed building , * (circle one) * Front yard ,.3 `eft Rear yard } r ft No . of stories (habitable space} * Side yards 2 Z, ft and ft Height ( grade to ridge ) �/ ~ ^ ft • If on corner , setback from side street ft If residential , no . of families OCCUPANCY INFORMATION No . of rooms ( excluding baths ) 5 x * No. of bedrooms_ � * PR BUILDING No . of bathrooms r- * s/"One family dwelling Primary heating system * Two family dwelling Type of fuel Multiple dwelling / Number of units * No . of fireplaces to be installed * Permanent occupancy Will a wood stove be installed? Transient occupancy * Central Air conditioning? * Business BUILDING STYLE, PRIMARY STRUCTURE * industrial * Other ' Ranch Contemporary Log cabin If addition , what will use be? Raised ranch Mansion Duplex Split level Old style Bungalow Cape Cod Cottage Other ACCESSORY BUILDING- Town House * Detached garage/one car/ two car/ car Colonial Row car/ car ( CIRCLE ONE PLEASE } * 6�ttached garage/one car/ Private storage building ESTIMATED MARKET VALUE OF * Other * CONSTRUCTION INFORMATION ON BUILDING SPECIFICATIONS , ON REVERSE 'SIDE OF THIS SHEET. TO BE COMPLETED ! Form BPA 4/86 and-vl BUILDING PERMIT APPLICATION CONTINUED - BUILDING SPECIFICATIONS : Type of construction , wood frame , fire safe , etc . "o Will any second12 -hand or ungraded lumber be used? If so , for what ? Foundation wall material '� � r Thicknessc5 e Thickness Depth of foundation below grade (to bottom of footing ) —� Will there be a cellar? u� i unheated? Floor sq. footage s ft Will there be a basemen ? [/� Will any portion be used as living space ? '_Jc � q ( If so , what portion? sY--cl , ft . _ _ Type of use., 'type of roof - sloped/flat/shed/other�_� Material of roof � Size , wood studs Z "x '" s acin " P 9_ c� o , c . length ft . 45 Joists ( floor beams ) 1st . floor '+ ++ X spacing__ r _ o . c . spanZc,/ ft , JOIsts ( floor beams) 2nd . floor x it spacing Ito , c . ,o , c . span ft . ©verlays ( ceiling beams ) '+x 1+ spacing o . c , span.ft Roof rafters "} " spacing o . c , span f't , Root trusses (pre-engineered) spacing Exterior wall finish rY Df what material ? Interior wall finish � _I;L � I��. +t Lr�d r�Q ire If a garage is to be attached , oescribe materials to be used for FIRE SEPARATION : Is there to be an opening between garage and dwelling? If so will a Fire-rated door , enclosure , and self-closing device be p ovided? Will a flue-lined chimney be installed? Height above ro f Depth of chimney foundation below grade ft . ft . Depth of firepl hearth ft , in . Water supply Munici a� or private well SEPTIC SYSTEM stance from ANY private well ( includin adjoining es ft * (A separate application is necessary for any repair or new installation eof�septic system) Town of Queensbuyy t V� County of Warren A F F I D A I T STATE OF NEW YORK I swear that to the best of my knowledge and belief the statements contained in this application , together with the plans and specifications submitted , are a true and complete statement of all proposed work to be done on the described premises and that all provisions of the BUILDING CODE , THE ZONING ORDINANCE , and all other laws pertaining to the proposed work shall, be complied with , whether specified or not , and that such work is authorized by the owner , SWORN TO BEFORE ME THIS Signature Owrk day of 19 r + owner ' s agen , arc ' zest, contractar Notary Public , Warren County, N . Y . * It * * * * * * * * * * * * * * * * It * * * * * * It * * * * * * * * * * * * * * * * at At SPECIAL CONDITIONS OF THE PERMIT : By TOWN OF QUEENSBU RY WARREN COUNTY . NEW YORK BUILDING Application for = STATE ENERGYCONSERVATIONCOMPLIANCE WITH THE NEW XORK CODE A permit must be obtained before beginning work. . ANSWER ALL of the following : 1 . Gross floor area f ' 2 , Type of heat G 3 . is the building mechanically coaled ? 4 . Percentage of area of windows and doors 7f� A , Over 16 % Only 1 . Uo value of gross area of walls , roof / ceiling and floors exposed to ambient conditions 2 . Floor over heated spaces YES NO a . Are foundation walls insulated ? YES NO 1 , if YES , what is the R value ? 3 . Slab on grade YES NO a , If YES , what is the R value of insulation around perimeter of floor ? 4 , is basement heated ? YES NO a . R value of insulation 5 . Type of insulation B . Under 16 % Only 1 . R value of roof and floors exposed to ambient conditions 2 , R value of exterior walls 3 . R value of glazed area 4 . R value of doors 5 . R value of floors over unheated spaces, L � 6 . R value of slab edge insulation - unheated slab 7 . R value of slab insulation - heated slab Be R value of heated basement/ cellar walls ( above grade ) 9 . R value of heated basement / cellar walls ( below grade ) 14 . Type of insulation C . Controls 1 . Thermostat maximum heat setting D , Duct Systems NO 1 . Is duct system installed in unheated spaces ? YES a . If YES , R value of duct installation b . R value of duct in other areas E . Piping insulation agent pipe 1 . size of hot water or cooling carrying a g 20 R value of pipe insulation F , Service Water Heating 1 . Performance efficiency maximum 2 . Temperature control setting G . For Swimming 'pool Only 1 . Maximum heating y�vr Telephone No . ' - 2,/ L) 1�-fnt ap 11 nts signature ) ...Il�Ir7L APPLICATION FOR SEPTIC DISPOSAL PERMIT DATE LOCATION OF PROPERTY FOR INSTALL�ON �iGf���rt � r•f � �` /!�� Owner's Name: AZZ Address: F / L Ur Installer's Name: f L L Telephone: Number of bedrooms (residential only) _ Total daily flow (compute @? 150 gal per bedroom) rT Topography: circle one Fla Rolling Steep Slope °10 of slope Soil Nature: circle one: Sand Loam Clay Other / Depth: fact Ground Water: At what depth? feet Bedrock or Impervious Material: At what depth? . feet Percolation test: circle one: not required required / rate min. inch. Domestic water supply: circle one Municipal Well Other IF domestic water supply* is a Well: €eat Separation: W atersupply from Septic absorption PROPOSED SYSTEM: Septic Tank 42M. gal. (minimum size: `1 ,000 gal.) TILE FIELD: Each Trench S feet / Total system length 4?.e+ � feet SEEPAGE PIT(S) : Number of / Size each €eet by feet Size of stone to be used It / Depth or Thickness feet I M P O R T A N T _..Please...LIST NEW EQUIPMENT TO BE INSTALLED (over) Section II Septic System Inspections: A, All applications for septic system installation, alteration or repair, as required by the Town of Queensbury Sanitary Sewage- Ordinance, shall be submitted to the Building Department at least 24 hours before start of construction and shall include a plot plan showing: 1 .) the proposed location of the system 2.) location and distance to lot lines 3 .) location and distance to structures 4.) location and distance to any water supply 5.) size and dimensions of all tanks, distribution boxes, tile fields and/or drywells B. No system shall be covered before inspection and approval by the building Inspector. Failure to comply with this requirement may result in the uncovering of the system by the installer and a fine of up to $250.00. c. An approved copy of the plot plan shall be available on the construction site. Failure to produce said plot plan at time of inspection may result in an immediate work stoppage. D. Should unforeseen problems during construction prevent proper installation., alteration or repair of an approved system , a new proposal must be submitted to the Queensbury Building Department before further construction. I have read the regulations above and agree to abide by these and. ,all requirements of the Town of Queensbury Sanitary Sewage Disposal. ()ed.innnce. Signature of responsible person; � .�o �, Date: Town of Queensbury Building and Code Department Bay at Haviland Road Queensbury, New York 1Z801 (518) 792-5832 SETTLED 1763 . . . HOME OF NATURAL BEAUTY . . . A GOOD. PLACE TO LIVE YORK BOARD OF FIRE UNDERWRITERS THE NEW BUREAU OF ELECTRICITY � di ESTATE STREET• ALB ANY, NEW YC7RK 12207 _ rslg Application ,vo. onfite 013023 / 87 A 7U4816 Dace ,January 19 . 1988 is ti,r.n n...m#1er in the Ass of THIS CERTIFIES THAT m and introduced by theapplicsnat .,,,e,medonthe .f.00eaPlP'ti� s only the etectrieat equipefte as de+Pcrif+�l beloweP L.awreaQe 3 . Fredellas COr Bonner Drive , t4ueano-bury . NY i Loc 2i Section Stock Lian; Bas,snnsen¢ tat Ft. � End Ft. outside uirementa of this Board. in the foltawing iaca and found to be in compliance with the req was examined on 1 1 i f 87 COOKING pECt[S 01lENS DISH WASHERS EXHAUST FANS RXTLIREs RANrGrEs OUTLETS A �' SWITCHES AMT. K. w. AMT. K. W. AMT. K-w. AMT. K. W. H- INCANLIESCEH7 FL11GItE5CEN7 ], 4 . 6 2 ]+`R i 4 34 16 14 UNIT "%^TMS WjLTI-OUTtEr DVAA M Ms SPECIAL REC'F T TIME CLOCK$ EELL SYSTEMS AMT. WATTS � DRYERS PIIRNACE AiWTORS ""URE APPLIANCE :�-� AMT. AMrs. TRANS. AMT. FI. r. NO. CIF SET M. ►. GAS N. P. AMT. P10. A. W. G. AMT- AMP. AMT, K- W- G1L $n '� 6 S V I E S E R C A.W. G. NOS. Oi A. W G NO. OF NFLEG A.W- G- NG. of FIEUTRAL4 OF T#ELITRAL SERVICE DiscommECT MEO. or No. o► cc. cGr+n. ON oP +II-LtG AMT. �. TYPE X 2W T jr aw s Ir 2w a 0 sW PER r GF cc- c D. 1 200 Gb 1 x y 4 t7 OTHER APPARATUS< t z- t;rcx 1— Smo'ke DetOCt.Or Electric poxg 'beater ' S : 2 . 0 KW 3� 1 . 5 KW 3- 1 . o KW 1- . 5 Lawrence Jo Nrede�i4a d J� 4 Cherry Street BRANCH MAmAC+ER J.�^' F35 icl J.lSs NYE Per This certificate must not be altered in any manner; return to the office of the Board i# incorrect. lnspectars mGY be ideni�fied by their credentials- altered FOR BUILDING ❑EpARTMENT. THIS COPY OF CERTIFICATE MUST MOT BE ALT@RED 1N ANY MANNER. - - I y ( j ' BUILDING and ZONING DEPARTMENT 1 Hay and- " avilan oad. R.L7. 1 Box 98 �sbury, w York 12$01 L SPECTORTS REPORT B NAME LOCATION Date rat /' L� Permit No , �S r * * * * * * * * * * APPROVED YES NO footing/Pier Forms Foundation Waterproofing Backf ill Framing Roof ing Siding Masonry Veneer Rough Plumbing Relief Valves 3?xt . Porches Finished Floors Interior Trim ------ -'- stairs & Railings - -----_ Cellar Chain Tile concrete Floors rlYbg , Fixtures Gar . Fireproofing Door Closers Smoke Detectors Chimney INSULATION Foundation Floors walls Ceiling_ FINAL EI ECTRICA INSPECTION �- RIVEWAY APPROV S rvey { al Building nsp action ( call when ready ) Next sched uled i Remarks- C�X/ E3uildi g Inspector C3/$� and-vl livn n/ 'Queen.Iiurry BUILDING and ZONING DEPARTMENT Bay and Haviland Road, R. D. 1 Box 98 Clueensbury, New York 12801 SEPTIC DISPOSAL S STEM INSPECTION NAME _ f LOCATION DATEt l 'PERMIT NO. F SOIL TYPE - Sand - Loam - Clay -_ Percolation Test Required? YES - NO Percolation rate - Min/Inch TYPE of SYSTEM: Absorption field , total len h Length of ch trench Depth of tr ches Size of gran SEEPAGE PITS4 er o' — Size- ft_ _ - Gravel size PIPING : Size "type Bldgw to tank Wank to dist. ,�� � . Dist . box to el Openings sea d? S NO Partial LOCATION/S RP,TION Foundation o tank L-'ft. Foundatio to absorp ' on eft_ Absorptio to lot lin _ft_ Separati of pits -•^ ft. I,OCATIC+N STEM ON P OPERTY (circle one) Front - r - Left Sid - Right side - COM.MEN ` (9r(! d . SYSTEM USE APPROVED YES NO Building Inspector 01/86 and vl ,�y� _burn a� �u €tBn36ttr� f � BUILmNG and zONING DEPARTMENT lip 1 Say and Haviland Road, R,D, 1 Box 98 oueensbury, New York 12801 SEPTIC DISPOSAL. SYSTEM /fINSPECTION NAMEL (ffj/ I L.00ATIOhI DATE f / - P E wyr I T NO. SOIL TYPE - Sand - Loam - C - Percolation Test Required? YES - No Percolation rate - Min/In _ TYPE of SYS EM: Absorption field , tota length_ f Length of IS h trench Depth of tr ches Size of grav — - SEEPAGE PITS{ er of) _ Size- ft. ft. Gravel size ' PIPING : Size Type Bldg . to tank Tank to disc_ Dist , box to f ' ld/ ' t openings Seale ? YE No Partial LOCATXON/SEP TIONS : Foundation t tank ft . Foundation t absorption ft . Absorption lot line £t . Separation pits ft . LOCATION OF SYSTEM ON PROPERTY (circle one ) Front - Rear - Left side - ght side - CCMMEN'TS SYSTEM USE APPROVED YESL,..� Building Inspector ol/86 and vl _Jown of Queens � urt� BUILDING and ZONING DEPARTMENT yr, Bay and Haviland Road. R.D. 1 Box 98 "�0► Oueensbury, New YOfk 12801 Il BUILDING INSPECTOR ' SS`` REPORT NAME LOCATION Dated ) 14j -_.. Permit No * r ,► * +� * * * * irk * APPRDVEL7* -* * S* NO Footing/Pier Forms_ Foundation Waterproofing Back.fill ��raming Roof In Siding Masonry Veneer Rough Plumbing Relief Valves Ext . Porches Finished Floors Interior Trim Stairs & Railings Cellar Drain 'rile Concrete Floors plbg . Fixtures Gar . Fireproofin Door Closers Smoke Detectors Chimney INSULATION : Foundation Floors Walls Ceiling FINAL ELECTRICAL INSPECTION�,,� DRIVEWAY A "PROVss Final Building Survey Next scheduled inspection (call when ready ) Remarks- Building Inspector 6/85 and-vl l� ! J flown Of 'Queenjl ury BUILDING and ZONING DEPARTMENT Bay Queensbu y. N w York 0 98 12801 BUILDING I NS7�P, ECTOR. ' S REPORT NAME LOCATION S'S'v Date 7 NO * * * * * APPROVED - YES Footing/Fier Forms Foundation Waterproofing B�' ack€ ill /�[ raming Roof ing Siding masonry Veneer VRaugh Plumbing Relief Valves Ex't , Porches Finished Floors Interior Trim Stairs & Railings Cellar Drain Tila� ---�- concrete Floors Plbg . Fixtures Gar , Fireproofing Door Closers Smoke 'Detectors Chimney It3SULATION Foundation Floors Walls Ceiling FINAL 'ELECTRICAL II3SPECTION DRIVEWAY APPROV Final Building Survey Next scheduled insp ection call when ready ) Remarks- fry j) WI A O Bu ' ds. g In c or 6/86 and-Vl _,Jaurn o� �ueeres � urt� BUILDING and ZONING DEPARTMENT Bay and Havifand Read, R.D- i 'Box 98 Queensbury, New York 12801 BUILDING INSPECTOR ' S REPORT NAME LOCATION_ lJC3wtii/r� ,�f �ttlL+'�. 4I4� Date_r / U I Permit. No * y' APPROVED - YE y NO (Footing/Pier Forms '�� Foundation waterproofing Backfill Framing Roofing Siding Masonry Veneer Rough Plumbing Relief Valves Ext . Porches Finished Floors Interior Trim Stairs & Railings Cellar Drain Tile Concrete Floors Plbg . ]Fixtures Gar . Fireproofing Door Closers Smoke Detectors Chimney INSULATION Foundation Floors Walls Ceiling FINAL ELECTRICAL INSPECTION DRIVEWAY APPROVAL Final Building SurveyT Next scheduled inspection (call when ready) Remarks- /"? � 757V wo IF Building Inspector 6/86 and-vl �osrrrll o� �ueee►� d6ure� SUii-DING and ZONING DEPARTMENT Bay and Hawiland Road. R.D. 1 Box 98 Queensbury, News York 12803 BUILDING INSPECTOR ' RT NAME L.oCAT I (3N ' Date. / Permit No IX APPROVED - ''YES NO Footing/Pier Forms Foundation terproofIng Apackfill F ra=i.ng Roofing Siding ,Masonry Veneer Bough Plumbing Relief Valves --� Ext . Porches Finished Floors Interior Trim Stairs & Railings Cellar Drain Tile {concrete Floors Plbg , Fixtures Gar , Fireproofing Door Closers Smoke Detectors Chimney 3EN SU LAT ION : Foundation Floors Walls Ceiling FINAL ELECTRICAL INsPECTIOI3 DRIVEWAY "PROVAL Final Building Survey Next scheduled Inspection (call when ready Remarks-- Building Inspector 6/86 and-VI /m7m�7c- o of Queer 'Jj "ry BUILDING and ZONING DEPARTMENT Say and Haviiand Road, }"t.Q. i Sox 96 QUeensbury, New York 12B01 BUILDING INSPECTOR ' S REPORT NAME L O C A T I ON yr y�r,• ,r. WLo'+� t^� pate — Permit No . * * * * * * * * * * * * * *APPROVED YR No Posting/Pier Forms Foundation Waterproofing Back.£ il1 Framing Roofing siding Masonry Veneer Rough Plumbing _^ — Relief Valves Ext . Parches Finished Floors Interior Trim stairs & Railings Cellar Drain Tile Concrete Floors plbg . Fixtures Gar . Fireproofing Door Closers smoke Detectors Chimney INsul ATION Faun da t i can Floors Walls Ceiling FINAL ELECTRICAL INSPECTION ORIVEWAY jkPVRoV Survey Final Building Next scheduled inspectican (call when ready ) Remarks- 0 lSui ing Inspector 6/86 and-vl BUILDING and ZGNING DEPARTMENT Say and Havifand Road, R.D. 1 Box 98 Queensbury. New York 12801 BUILDING INSPECT R ' S REPORT NAME t1! 40 frV LOCATION // (/d? r"'I' r (A-ld / ! f ►' J Da1�e permit ttilo . c * * « APPROVED - YES O Xoting/Pier Forms Foundation Waterproofing Backfill Framing Roofing Siding Masonry Veneer Rough Plumbing Relief Valves Ext . Porches Finished Floors Interior Trim Stairs & Railings — Cellar Drain Tile Concrete Floors a Plbg . Fixtures Gar . Fireproofing Door Closers Smoke 'Detectors Chimney IN SU IAAT I O14 Foundation Floors Wa 11. s Ceiling FINIAL ELECTRICAL INSPECTION I)RIVEWAY APPROV Final Building Survey insp action (call wh Next scheduled en ready ) Remarks- orr w� �S e) JV lie; Building Inspector �/85 and-vl `7 nslurry awn o� Quee BUILDING and ZONING DEPARTMENT Bay and Haviland Road, R, D, I Box 98 Queensbury, New York 12801 BUILDING INSPECTOR ' S REPORT NAME LOCATION E C Date1g7 �s� Permit No . _._ APPROVED YES NO mooting/Fier Forms Foundation waterproofing Backfill Framing Roof in g Siding Masonry Veneer Rough plumbing Relief Valves Ext , Porches Finished Floors - � Interior Trim Stairs & Railings _ Cellar Drain Tile Concrete Floors Flbg . Fixtures Gar . Fireproofing Door Closers Smoke Detectors Chimney I N S LI I.AT I ON Foundation Floors walls Ceiling FINAL ELECTRICAL INSPECTION_ _ DRIVEWAY APPR(WAL Final Building; Survey Next scheduled inspection (call when ready ) Remarks- Building Inspector 6/86 and-vl BUILDING DEPT. COPY OF APPLICATION FORM 46-EL, NEW YORK BOARD OF FIRE. UNDERWRITERS. FILE THIS COPY WITH BUILDING DEPT. WHEN REQUIRED. T'EMIP. fl CATE .� . CITY OR VILLAGE TOWNSHIP COUNTYYoe "± STREET AND NO. OR /""� ROAD AND POLE NO. 6 4 POLE TI BETWEEN WHAT TWO '" EGTSON BLOCK LOT _,r.. CROSS STREETS IS ,. PREMISE L TEOT I OCCUPANT'S ILOING NAME OCCUPANCY r ONNEWS NAME AND ADDRESS SUPPLIED - : . i �^ FROM THEIR :--{ / "- . . .:. ! ?+' OFFICE BY OEPECTS II3UILDING LL NEW l,/ OLD ❑ I RK NEW C;k ADDITIONAL ❑ REMOVfO ❑ LIST BELOW ALL EQUIPMENT WHICH YOU INSTALLED No. of Fixtures A BRANCH OFFICE USE NUMBER OF OUTLETS Lamp Reasplimes MOTORS HEATERS CIRCUITS Los+ ONLY H.P. wSide No. TYs Each Eaacrnh GntA'w'GtimCallkip n1Swsss INSPECTION SdRaa •k Out- okbs Sub- be" Bass- nsant 1st FI, 2nd Ft. 3rd Fi. REMARKS: LIST OTHER ELECTRICAL DEVICES NOT SET FORTH ABOVE: DO NOT USE THIS SPACE. This appiica ti orl is intended to cover the abort-IisSad w Wipment to he inspec bad but I at tuna of inspection there is found sddiYional equipment not also" listed• you are authotiard to make the inspmtion and adjust the far to crwrr the additional equip bent, as Pro kw by tha OV08"nE SIZE OF ELECTRIC SIGN TOTAL MAINS FEEDERS LAMPS WATTS CHARACTER EXPOSED GAS TUBE SIGN OF WORK CONCEALED1 TRANSFORMERS OF VA WORK TO BE #NUMBER} ICAPACITYI STARTED COMPLETED SIZE OF SIGN SERVICE OVERHEAD UNDERGROUND MAKER ENTERS OF SIGN BUILDING INSPECTION REQUESTED �O'i7SS BAS NEAR AS NEW � OLD LE AVOID DELAY BY GIVING FULL AND ACCURATE INFORMATION. ALL SPACES DATE OF MUST BE FILLED WJ OR APPLICATION MAY BE RETURNED. APPLICATI PRINT NAME D ADDRESS "r NAME OF -.-� SIGNATURE - APPLICANT Of APPLICANT f-7 # i STREET ADDRESS etz iulo Ce TELEPHONE -2 �4ry ENSE NO- CITY OR ZIP WHEN APPLICABLE POST OFFICE c- oL CODE ... ae EL (REV, 1/86) A SEPARATE APPLICATION MUST BE FILED FOR EACH SEPARATE BUILDING 1. {5 �W i \ 1� 17F ` p S'S � Q ` 6 C � 6 AID 5 c7IG o :(//eo f3